Written by: Vytas Karalius, MD, MPH (NUEM ‘22) Edited by: Nery Porras, MD (NUEM ‘21) Expert Commentary by: Kevin Emmerich, MD, MS
Today’s post was inspired by the near-hanging of young gentleman who ended up passing away due to complications related to his near-hanging. His parents decided to donate his organs to Gift of Hope, allowing the passing of his life to extend the lives of others. While we hope to never see cases like these, they are an inevitable part of our job as emergency medicine physicians. As with most rare and complex pathology, preparation and knowledge can help us with the management of these cases when things often get chaotic. Lastly, as emergency medicine physicians who see the sequelae of mental illness daily in their EDs, I encourage us all to advocate for better funding and access to mental health care in the United States.
Hanging Injury
Terms/Classification [1]
“Hanging” is used to describe a death from a form of strangulation that involves hanging from the neck.
“Near-hanging” is a term for patients who have survived an attempted hanging (or at least long enough to reach the hospital).
“Complete hanging” defines when a patient’s legs are fully suspended off the ground and the patient's bodyweight is fully suspended by the neck.
“Incomplete hanging” defines when some part of the patient’s body is still on the ground and the body's full weight is not suspended off the ground.
“Judicial hanging” classically refers to victims who fell at least the height of their body.
Epidemiology:
Hanging is the 2nd most common form of successful suicide in the US after firearms
Accounts for 23% of >34,500 suicides in 2007
In the jail system, hanging is the most common form of successful suicide
Increasing incidence in US
Risk Factors: male, aged 15-44 years, history of drug or alcohol abuse, history of psychiatric illness
Pathophysiology of Injury:
Spine/Spinal Cord:
When the drop is greater than or equal to the height of the victim, as in a judicial hanging, there will almost always be cervical spine injury.
The head hyperextends, leading to fracture of the upper cervical spine ("hangman's fracture” of C2) and transection of the spinal cord.
Cervical injuries are in non-judicial hangings are rare. [2] One retrospective case review of near-hangings over a 10-year period found the incidence of cervical spine fracture to be as low as 5%. [3]
Vascular:
The major pathologic mechanism of death in hanging/strangulation is neck vessel occlusion, not airway obstruction. [1,4]
Death ultimately results from cerebral hypoxia and global ischemia.
There are two mechanisms by which this happens:
Venous: The most implicated cause of death is actually venous obstruction. Jugular veins are superficial and easily compressible. Obstruction of venous outflow from the brain leads to stagnant hypoxia and loss of consciousness in as little as 15 seconds.
Arterial: The risk of damage to the major arterial blood flow to the brain (such as carotid artery dissection) is rare, but should suspected in patients. [4]
Cardiac:
Carotid body reflex-mediated cardiac dysrhythmias are reported, and likely a minor mechanism of death.
Pulmonary:
Airway compromise plays less of a role in the immediate death of complete hanging/strangulation. However, it is a major cause of delayed mortality in near-hanging victims. [1,4]
Significant pulmonary edema occurs through two mechanisms:
Neurogenic: centrally mediated, massive sympathetic discharge; often in association with serious brain injury and a poor prognostic implication.
Post-obstructive: strangulation causes marked negative intrapleural pressure, generated by forceful inspiratory effort against extra-thoracic obstruction; when the obstruction is removed, there is a rapid onset pulmonary edema leading to ARDS.
Aspiration pneumonia later sequela of near-hanging injury.
Airway edema from mechanical trauma to the airway, which can make intubation difficult.
Tracheal stenosis can develop later in the hospital course.
Other Injuries:
Hyoid bone fracture
Cricoid or thyroid cartilage injury [5]
Physical Examination:
"Ligature marks" or abrasions, lacerations, contusions, bruising, edema of the neck
Tardieu spots of the eyes
Severe pain on gentle palpation of the larynx (laryngeal fracture)
Respiratory signs: cough, stridor, dysphonia/muffled voice, aphonia
Varying levels of respiratory distress
Hypoxia
Mental status changes
Early Management/Stabilization:
ABCs as always
Early endotracheal intubation may become necessary with little warning.
Patients who are unconscious or have symptoms such as odynophagia, hoarseness, neurologic changes, or dyspnea require aggressive airway management.
If ETI unsuccessful, consider cricothyroidotomy; if unsuccessful, percutaneous trans-laryngeal ventilation may be used temporarily.
Judicious and cautious fluid resuscitation - avoid large fluid volume resuscitation and consider early pressors, as fluids increases the risk/severity of ARDS and cerebral edema.
Monitor for cardiac arrhythmias.
The altered/comatose patient should be assumed to have cerebral edema with elevated ICP.
Imaging/Further Testing:
Chest radiograph
CT brain
CT C-spine
CTA head/neck
Can consider soft-tissue neck x-ray, if CT not immediately available
Further Management:
In patients with signs of hanging/strangulation, there should be a low threshold to obtain diagnostic imaging/testing as discussed above.
Expect pulmonary complications early.
They are a major cause of delayed mortality in near-hanging victims, as stated above.
Early intubation and airway management are important.
Non-intubated patients with pulmonary edema may benefit from positive end-expiratory pressure ventilation.
Patients with symptoms of laryngeal or tracheal injury (e.g. dyspnea, dysphonia, aphonia, or odynophagia), should undergo laryngobronchoscopy with ENT. [4,6]
Tracheal stenosis has been reported during the hospital course. Address cerebral edema from anoxic brain injury, using strategies to reduce intracranial pressure or seizure prophylaxis. [4]
Address vascular complications seen on CTA and coordinate intervention with the appropriate specialty at your institution.
Therapeutic Hypothermia
There is some evidence for therapeutic hypothermia in those with cardiac arrest from hanging injury [7,8] and those who are comatose from hanging injury. [9-11] While the evidence is weak, in the absence of better evidence, it is reasonable to consider hypothermia treatment in all comatose near-hanging victims. [1,12,13]
When suicide is suspected, evaluate patients for other methods of self-harm (e.g. wrist lacerations, self-stabbing, ingestions). It is also important to consider drug and alcohol intoxication. [4]
Disposition:
Admit critically ill patients to the appropriate ICU-level care.
Admit patients with abnormal radiologic or endoscopic imaging to the appropriate service and level of care.
Even if the initial presentation is clinically benign, all near-hanging victims should be observed for 24 hours, given the high risk of delayed neurologic, airway and pulmonary complications. [14]
Observe asymptomatic patients with normal imaging.
Psychiatry/Crisis Team consult on all suspected intentional cases.
Emphasize strict return precautions as well as education about possible delayed respiratory and neurologic dysfunction when discharging patients.
Some patients may require transfer to a trauma center if the required services are not available at the initial receiving facility. [1]
Prognostication:
GCS 3/GCS 3T is a predictor of very poor outcome, [15-19] but there is mixed evidence on the GCS as a predictor of outcomes in GCS scores greater than 3, especially with regard to neurologic intactness. [3,19]
Recovery of patients with neurology symptoms is unpredictable. [4]
Patients presenting with cardiac arrest have a very poor prognosis, and might be the strongest predictor of poor prognosis. [4,8,16,18,20]
Other predictors of poor clinical outcome include:
Anoxic brain injury or cerebral edema on head CT [3,19]
Prolonged hanging time [18]
Cardiopulmonary arrest [8,11,19]
Cervical spine injury
Hypotension on arrival
Expert Commentary
We’ve all certainly been involved with a patient with reported hanging injury at some point in our time in the ED. They are usually unimpressive if a person does it as more of a gesture rather than a true suicide attempt. When they are unfortunately done “correctly,” they usually result in a trip to the morgue instead of the ED. When the swiss cheese holes align and a true hanging attempt results in a serious but not fatal presentation, things can get quite hairy. I’ve been a part of one such case, and will never forget it. Here are my two cents.
Airway
This should undoubtedly be treated as a predicted difficult airway, not only due to likely cervical spine trauma, but also possibly due to airway edema. Get your ducks in a row for this unless this patient is crashing in front of you. Get your consultants/help (if available), preoxygenate, airway adjuncts open and ready, backup airway supplies if your first plan fails. Most importantly, have a plan and discuss this with your team beforehand. Don’t be afraid to take an awake look with a hyperangulated video laryngoscope, especially if this patient presents with stridor. Ketamine can be your friend here. This should be an airway that you do not undertake without a scalpel, finger, and bougie ready just in case. I like to draw a line on the patient’s skin overlying the cricothyroid membrane beforehand.
Trauma
Self explanatory, but don’t be stingy here. Light this patient up from head to pelvis, including the neck angiogram. Document a repeat neuro exam every time you move this patient.
Overdose/psych
Don’t forget your Tylenol and salicylate levels, EKG in this suicide attempt. If you feel the need to add the useless urine drug screen, I suppose this is fine as well.
Kevin Emmerich, MD, MS
Emergency Medicine Physician
Methodist Hospital
Gary, Indiana
How To Cite This Post:
[Peer-Reviewed, Web Publication] Karalius, V. Porras, N. (2021, Aug 9). Hanging Injuries. [NUEM Blog. Expert Commentary by Emmerich, K]. Retrieved from http://www.nuemblog.com/blog/hanging-emergencies
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References
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